“If you use them,” Cron said, “you want to do it in patients who have an overly exuberant immune response.”
The UK trial that tested dexamethasone found that only some hospital patients benefited from it. In this case, they were those who were sick enough to need oxygen or a mechanical ventilator. The drug reduced their risk of dying from a fifth to a third.
But when hospital patients were not on life support, the drug was of no use.
The current study found a different dividing line: blood levels of a substance called C-reactive protein (CRP), a marker for inflammation.
If patients’ CRP was high (20 mg / dL and above), steroid treatment reduced the risk of death or ventilation by 77%.
But if CRP was low (less than 10 mg / dL), corticosteroid therapy more than doubled those risks, the study authors reported.
This finding is perhaps the most significant, according to study co-author Dr. Shitij Arora, a hospitalist in Montefiore and associate professor at Albert Einstein College of Medicine in New York.
It highlights a group of patients, Arora said, who could in fact be harmed by steroid treatment.
CRP tests are standard and inexpensive, according to Arora. But it’s not clear whether CRP alone is the best way to identify patients who should be on steroids, he said. Other lab tests, in combination with CRP, could be even better, said Arora and Cron.
And is prednisone as good as dexamethasone?
Arora said he suspects the benefits of dexamethasone reflect a “class effect” and are not limited to this drug alone. But, he stressed, it is an “opinion”. Clinical trials are needed to prove that a treatment works.
Ongoing studies are testing other steroids. For his part, Cron said he would be “very surprised” if dexamethasone was the only effective one. Having additional options would be a good thing, he noted, so that the world does not depend on one drug.
The results were published online July 22 in the Journal of Hospital Medicine.
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SOURCES: Shitij Arora, MD, associate professor, medicine, Albert Einstein College of Medicine and hospitalist, Montefiore Medical Center, Bronx, NY; Randy Cron, MD, PhD, professor, pediatrics and medicine, director, pediatric rheumatology, University of Alabama at Birmingham;Hospital Medicine Journal, July 22, 2020, online
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